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expectation that bereaved OMEGA—Journal of Death and Dying 2017, Vol. 74(4) 455–473 ! The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0030222817691870, Utrecht University, Utrecht, the Netherlands 2 Department of Clinical Psychology & Experimental Psychopathology, University of Groningen, Groningen, the Netherlands 3 Department of Gerontology, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston, Boston, MA, USA Corresponding Author: Margaret Stroebe, Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands. Email: m.s.stroebe@uu.nl persons will, even should, go through stages of grieving can be harmful to those who do not. Following such lines of reasoning, we argue that stage theory should be discarded by all concerned (including bereaved persons themselves); at best, it should be relegated to the realms of history. There are alternative models that better represent grieving processes. We develop guidelines to enhance such a move beyond the stage approach in both theory and practice. Keywords Stage theory, Ku¨bler-Ross, Bereavement, Grief, Review Theoretical models of bereavement should serve the function of increasing understanding of grief and grieving, particularly given the physical and mental health ramifications of this severe life event (Parkes, 1972/1996), which may require professional intervention (Shear, 2015). Among these approaches, socalled stage theories, postulating that grief progresses through specific emotional stages, have remained highly influential. Indeed, such adoption of a stage approach follows a long tradition in psychology (e.g., in developmental, health, social, and clinical domains) as well as in psychiatry and medicine. A stage theory can offer new ways of understanding complex systems of human behavior, ways that may be helpful for diagnostic purposes and to guide intervention (McGorry, 2007). However, those stage theories that have proven valuable show the evidence of scientifically based principles (e.g., postulating discrete changes in the nature of underlying stage-related processes or cognitive levels, providing empirical evidence for a sequential progression/for efficacy in treatment). Does the stage theory of grief meet such criteria? Is it a valid and useful model of grief and grieving? Answering such questions requires evaluation of both its scientific and practical value. Therefore, the aim of this article is to review and assess the contribution of the stage theory of grief. To this end, in the next section, we trace how stage theory emerged historically, documenting its remarkable, persisting popularity in the face of ongoing opposition. Then we focus on emergent lines of argument against stage theory, covering conceptual concerns, lack of empirical validity, its failure to assist in identifying those at risk or with complications, and the potentially negative consequences for bereaved persons themselves. As we show, the stage theory of grief falls short in all these respects. There is no scientific foundation, and decades of research have shown that most people do not grieve in stages. Using stages as a guide in work with bereaved is unhelpful and may even cause harm. Our critical assessment leads to the conclusion that stage theory should be relegated to the past and eliminated from contemporary clinical practice. We discuss what actions can be taken to move on, suggesting an alternative approach and providing initial guidelines for health-care professionals and bereaved persons. 456 OMEGA—Journal of Death and Dying 74(4) Stage Theory in Historical Perspective: Claim and Refutation The emergence of stage theory is usually ascribed to Elisabeth Ku¨bler-Ross’s (1969) monograph ‘‘On Death and Dying,’’ which documented her observations of adjustment among dying patients. In essence, Ku¨bler-Ross’s stage perspective held that dying people go through five stages of grieving: denial, anger, bargaining, depression, and, finally, acceptance (sometimes called the DABDA model). Each stage was described in a separate chapter, with ‘‘stage’’ in the heading of these, strongly suggesting that they were distinct and sequential, even linear (although minimal acknowledgment of fluctuations between stages, individually varying time sequences, and coexisting stages can be detected on close reading). Later, in reintroducing the stages and focusing more on the bereaved (Ku¨blerRoss & Kessler, 2005), this was contested (though separate, sequential descriptions remained). It is important to note that Ku¨bler-Ross herself extended the application of the stages of dying to the situation of (anticipatorily) bereaved persons already in her 1969 book. Excerpts from her chapter ‘‘The Patient’s Family’’ make this clear: Family members undergo different stages of adjustment similar to the ones described for our patients. At first many of them cannot believe it is true. They may deny the fact that there is such an illness in the family. . . . Just as the patient goes through a stage of anger, the immediate family will experience the same emotional reaction. . . . When anger, resentment, and guilt can be worked through, the family will then go through a phase of preparatory grief, just as the dying person does. (Ku¨bler-Ross, 1969, pp. 168–169) In the decades following
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